This two-page case study measures your mastery of ULOs 2.3, 3.2, and 5.1. As a future healthcare professional, your role includes making clinical documentation clear, accurate, and compliant with

Patient Name: Walter Moran
Age: 68
Gender: Male
Date of Admission: January 10, 2025
Chief Complaint: Shortness of breath

History of Present Illness (HPI):
"Patient reports feeling ‘winded’ for the past week. No known triggers. Has history of heart issues. Physical exam shows irregular breathing sounds."

Past Medical History (PMH):

• Hypertension

• Diabetes Mellitus (type unspecified)

• Heart Disease

Medications:

• Lisinopril 10mg, daily

• Metformin 500mg, twice daily

Physical Exam:

• General: Patient alert, cooperative.

• Cardiovascular: Heart rate irregular. No murmur noted.

• Respiratory: Slight wheezing on auscultation.

• Neurological: Normal exam.

Assessment/Plan:

• Assessment: "Patient likely has COPD. Start inhaler."

• Plan: "Follow up in two weeks."